Nokea
The nurse is reviewing lab work for a client whose blood CO2 level is elevated. The nurse is most correct to suspect an impairment of which?
- A. Alveoli
- B. Bronchi
- C. The pulmonary artery
- D. The pulmonary vein
Correct Answer: A
Rationale: Gas exchange occurs in the lung where oxygen in inspired air exchanges for CO2 in the venous blood. The CO2 is then transferred to the alveoli to be exhaled. No gas exchange occurs in the bronchi. The pulmonary artery carries deoxygenated blood to the lungs, and the pulmonary vein brings oxygenated blood back to the heart to be pumped to the tissues.
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Which suggestion can the nurse provide to an older adult client to reduce the symptoms associated with sarcopenia?
- A. Maintain hydration.
- B. Avoid heavy lifting.
- C. Practice brisk walking.
- D. Limit the use of caffeine.
Correct Answer: C
Rationale: Sarcopenia refers to changes in composition of muscle tissue that can occur in aging because of deconditioning; therefore, increasing daily exercise helps to improve muscle strength, including the heart. Maintaining hydration is important for a client who requires cardiac catheterization to flush the dye used during the procedure from the system and is not an intervention supported by evidence-based practice guidelines for the client who experiences sarcopenia. Heavy lifting is discouraged following cardiac catheterization; however, avoiding lifting is not an activity that reduces symptoms associated with sarcopenia. The nurse discourages the use of caffeine for clients who experience tachycardia; however, this is not an appropriate suggestion to reduce the symptoms associated with sarcopenia.
The nurse provides care for a dying client following a massive myocardial infarction (MI). The nurse notes the client is experiencing dyspnea and has a barely palpable pulse. Which documentation of pulse quality by the nurse is appropriate?
- A. The client's pulse is full.
- B. The client is exhibiting a thready pulse.
- C. The client is experiencing a pulse deficit.
- D. The client's pulse indicates a regular rhythm.
Correct Answer: B
Rationale: When taking a client's pulse, the nurse notes its rate, rhythm, and quality. The pulse quality refers to its palpated volume. Pulse volume is described as feeling full, weak, or thready, meaning barely palpable. Documentation that the client's pulse is full is inaccurate. The nurse also determines any pulse deficit by counting the heart rate through auscultation at the apex while a second nurse simultaneously palpates and counts the radial pulse for a full minute. The difference, if any, is the pulse deficit. Documenting that the client's pulse indicates a regular rhythm is inaccurate because the documentation in this scenario focuses on the quality, not rhythm.
The nurse is discharging a client after a cardiac catheterization. What would the nurse include in the discharge teaching?
- A. Eat only soft foods for the next 12 hours.
- B. Report any numbness, tingling, or sharp pain in the extremity.
- C. Restrict your intake of water until the dye is out of the body.
- D. Move around whenever the client feels like getting up.
Correct Answer: B
Rationale: Instructions for the client and family include: Keep the extremity straight for several hours and avoid movement; Report any warm, wet feeling that may indicate oozing blood, numbness, tingling, or sharp pain in the extremity; Drink a large volume of fluid to relieve thirst and promote the excretion of the dye. There is no need to eat only soft foods after a cardiac catheterization.
In which client does the nurse consider the presence of an S3 heart sound to be normal?
- A. In a client who is in elementary school
- B. In a client who is an older adult
- C. In a client with an indwelling pacemaker
- D. In a client who is diagnosed with heart failure
Correct Answer: A
Rationale: A heart sound that follows S1 and S2 is called an S3 heart sound, or a ventricular gallop. Although an abnormal finding for many clients, this finding is considered normal in many pediatric clients, including a school-age client. In adults, the presence of S3 may signify heart failure, so this is not considered normal. Additionally, S3 is not considered normal for older adult clients nor for a client who has an indwelling pacemaker.
While being prepared for echocardiography, the client asks nurse why this test is necessary. What would be the nurse's best response?
- A. This test will find any congenital heart defects.
- B. This test can tell us a lot about your heart.
- C. Echocardiography is a way of determining the functioning of the left ventricle of your heart.
- D. Echocardiography will tell your doctor if you have cancer of the heart.
Correct Answer: C
Rationale: Echocardiography uses ultrasound waves to determine the functioning of the left ventricle and to detect cardiac tumors, congenital defects, and changes in the tissue layers of the heart. Explaining the procedure is the best answer because it addresses the client's question without making the client anxious or minimizing the question.